Matching system hinges on young doctors being available and ready to start caring for patients in July; programs can't risk having empty seats.

Dr. Amin Rabiei knew he wanted to work in medicine from an early age. While growing up in Iran, he watched his dad experience seizures and his mom struggle to help. Rabiei went on to medical school in Iran, then practiced at a rural clinic there, all the while working toward an important career point that culminated Friday: getting matched to a medical residency training program in the United States.

"I decided to come here to have better opportunities for research and clinical education," said Rabiei, who is already in Philadelphia on a research visa doing postdoctoral research at Thomas Jefferson University. His ultimate aim? "Hopefully, to share this information and these skills for the people who need this in the undeveloped countries."

Rabiei hopes to train in neurology with a focus on epilepsy. For international medical graduates like Rabiei, becoming eligible for residency training in the U.S. is a rigorous process that can take years of planning, financing and work. In general, landing one of these coveted spots, a requirement for anyone aspiring to train and practice medicine in the U.S., is already competitive; about 32,000 slots are available to an applicant pool of 42,000. Last year, about half the applicants from outside the U.S. were successful in getting a match.

But this year, in the run-up to Match Day, Rabiei and others worried that the recent White House executive orders on immigration had further diminished their chances of getting a match.

"It becomes like double stress," Rabiei said.

"It is a valid concern," said Dr. William Pinsky, president of the Educational Commission for Foreign Medical Graduates. And that valid concern continued, even though the most recent executive order on travel was blocked nationwide, at least temporarily, last week.

Here's why: Pinsky says President Trump's executive orders have created new unknowns in the visa process for foreign medical graduates -- and the ambiguity puts the residency programs, as well as the applicants, in a bind. Though the training programs rank applicants according to their merits and qualifications, the matching system hinges on these young doctors being available and ready to start caring for patients in July. Many residency programs can't risk having an empty seat because of visa processing delays.

"Program directors have to weigh various factors of applicants, from their medical knowledge, ability to communicate, their observed level of empathy, their leadership capabilities -- and their ability to be available when July 1 comes," Pinsky said.

He estimates that roughly 300 to 400 applicants this year from the countries covered by the White House executive orders would now need to apply for a visa -- or change or renew the one they have -- to train in the U.S.

About 1,800 people from these countries are already in medical residencies in the United States.

Further complicating this year's "match week," most residency programs ranked their preferences of applicants on Feb. 22 -- in between the issuing of the first and second executive orders on travel restrictions. Those match decisions were released Friday.

"The timing and uncertainty of the executive order could not have come at a worse time," Pinsky said.

The first White House executive order restricting travel came out in January and applied to seven Muslim majority countries: Iran, Iraq, Libya, Somalia, Sudan, Syria and Yemen. The more recent version, announced in early March, removed Iraq from the list. It bans new visas from the remaining six countries for 90 days, but also includes some exceptions that allow U.S. entry -- such as for lawful permanent residents of the U.S. and those with other valid documents.

The Educational Commission for Foreign Medical Graduates, which is based in Philadelphia, is responsible for certifying all international graduates who wish to apply for residency and practice medicine in the U.S. This involves administering qualifying exams and overseeing other background checks. ECFMG is also closely involved in the visa process, as a main sponsor of J-1 clinical visas for international graduates -- the most common type of visa granted for training and practicing medicine in the United States. A smaller number of institutions may directly sponsor residents through an H-1B visa.

"If someone has a visa, as I understand, even though they're from one of these six countries, it's not an issue," Pinsky said.

Even so, it's still unclear who is eligible to get a visa or how long it will take. His organization is awaiting clarification from the federal government on that process and whether, as before, the process can be expedited in order to be completed by the start of a medical residency.

"I think our bigger institutions, like Penn and CHOP [Children's Hospital of Philadelphia], have very much said, 'Just on principle we're going to rank these people if we think these are the best people,'" Grover said.

"You know, if I'm Penn and I've got an internal medicine class of, like, 45 residents, maybe I can take more of a chance. If one resident doesn't come maybe I can figure it out." (Indeed, a spokesperson from Penn said they don't think the executive order will impact the institution's ability to train residents who match there.)

But waiting for somebody's visa to come through can be a greater risk for smaller programs, Grover said. "You can't afford to lose 10 or 25 percent of your class. It'd be a big gamble for them."

Dr. Robert Wimmer heads a small pediatric residency program at Einstein Medical Center in North Philadelphia, and said about half the residents there are medical graduates from another country. The program can't afford to accept someone in their new class of 10 if there's a chance they might not be able to start in July because of visa issues.

"It's unfortunate," Wimmer said. "Many work their tails off to get to the U.S. We might be losing a lot of talent."

While the United States has long been known as an epicenter for top medical research and care, Pinsky worries that reputation and the whole system could suffer if an uncertain immigration climate discourages young doctors from trying to train and practice in the United States.

"There could be an issue of access to health care as well as a quality situation," he said.

Rabiei said he and his Iranian peers are trying to stay positive.

They feel encouraged by the support they've received from colleagues and their universities.

"When you try so hard to get to your dream, and all of a sudden you feel that there are some issues -- unexpected problems -- it's a really bad feeling," he said.

Rabei was thrilled to learn Monday that he has been offered a position by at least one institution. He knows other Iranians who were not so lucky. And on Friday, he got very good news: He matched with Drexel University College of Medicine. He will be able to stay in the United States -- and even in Philadelphia.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Clinical Quality Measures 101Although quality-reporting programs such as meaningful use provide incentives to help providers implement and use electronic health records (EHRs) to collect and report on clinical data, practices often need help deciding what data to collect, which measures to report ...

Credible, Defensible EstimatesIn healthcare, every interaction with the patient matters. Especially in today’s environment of continuous improvement, efforts have been concentrated on coordination among providers, the patient care experience and quality outcomes – all laudable goals.

Debunk the Myth: Outsourcing Doesn't Mean Losing ControlWith shifts in payer mixes and reimbursement structure, the margin of reimbursement has been shrinking steadily over the last five years. How do revenue cycle leaders navigate payment reform while maintaining stable business office operations?

Care Collaboration Success for Improved OutcomesThe nature of our healthcare ecosystem has been one of siloed care. Rarely do payers, providers and local resources come together with the patient's well-being prioritized as a unifying mission. Read how these organizations are getting it right.

Clinical Quality Measures 101Although quality-reporting programs such as meaningful use provide incentives to help providers implement and use electronic health records (EHRs) to collect and report on clinical data, practices often need help deciding what data to collect, which measures to report ...

Credible, Defensible EstimatesIn healthcare, every interaction with the patient matters. Especially in today’s environment of continuous improvement, efforts have been concentrated on coordination among providers, the patient care experience and quality outcomes – all laudable goals.